Contract Pharmacy Details

WISCONSIN CVS PHARMACY, L.L.C.
DSH520009 Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Covered Entity Details

Entity Name

Ascension NE Wisconsin, Inc. d/b/a Ascension NE Wisconsin - St. Elizabeth Hospital Campus

Subdivision Name

Type

Disproportionate Share Hospital

340B ID

DSH520009

Entity Address

1506 S. Oneida St.
Appleton, WI 54915

Medicare Provider Number

520009

Participating Start Date

4/1/2012

Last Recertification Date

8/19/2024

Pharmacy Details

Pharmacy Name

WISCONSIN CVS PHARMACY, L.L.C.

Pharmacy Address

DBA: CVS/PHARMACY # 05186
1485 ONEIDA ST.
APPLETON, WI 54915

Pharmacy Comments

Contract Details

Approval Date

1/11/2022

Contract Begin Date

4/1/2022

Carve-In Effective Date

Contract Comments

Contacts

Covered Entity Signing Official

Vanessa Freitag, Vice President, Pharmacy
(715) 897-1183

Contract Pharmacy Representative

CVS Health
Christian J Reid, 340B Program Director
(401) 374-9782

Signed By Date

1/11/2022

340B Drug Pricing Program Database